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The Sandilands junction tram accident: the importance of blame-free confidential reporting, and the role of CIRAS

Richard Booth, independent CIRAS committee member

The views expressed in this article are those of the author and do not necessarily reflect those of CIRAS.

This post suggests the role that CIRAS, the confidential reporting and analysis service for the transport sector, could have played in drawing attention to the underlying factors responsible for the Sandilands accident. TOL (Tram Operations Limited) is now a member of CIRAS, but at the time of the accident they were not.

Drivers were hesitant to report errors to their supervisors, but a CIRAS report, by just one driver, might have alerted TOL to the risks of overturning.

Though TOL was not a subscriber, the RAIB report (December 2017) highlighted that:

"226 …a Croydon tram driver contacted CIRAS on 4 March 2013 about a concern they had about fatigue arising from TOL’s roster. In response, TOL reported to CIRAS that rosters are only implemented following consultation with trade unions and the completion of an assessment of the roster using the HSE’s fatigue risk index (FRI). On this occasion TOL stated that the FRI assessment had not identified any areas of concern with the 2013 roster."

An underestimation of the risks

The tram overturned attempting to negotiate a very sharp curve at 45 mph compared with a speed limit of 12 mph. In two earlier posts, I concentrated on the flawed role of the regulator and the ‘mindset’ of the tramway teams carrying out risk assessments. For more background analysis, these posts can be viewed here:

In summary, everyone responsible thought that the consequences of excessive speed in tight bends was not potentially catastrophic; and sufficiently controlled by driver training/experience and speed limit signs. It was in any event a challenge:

“251 The only warning provided to tram drivers approaching the curve at Sandilands in darkness was a sign that was not visible until the driver had passed the point at which the tram’s speed could [only] be reduced to the required speed by application of the hazard brake. No other mitigation, other than drivers’ route knowledge, was provided against the risk of travelling around the curve at excessive speed.”

Moreover, three tunnels immediately before the turn perhaps acted as a disorientating ‘error trap’, as explained in Part 1. This kind of trap is also referred to in a CIRAS case study about the derailment at Santiago de Compostela which can be viewed here.

What went wrong with communications at Croydon?

“Engine-drivers constantly complain, and with very good reason, of the way in which signals are frequently placed; but it is only in rare cases, or after an accident …, that their complaints receive attention, or that improvements are introduced.”

Stretton, CE (1893) “Safe Railway Working” [Emphasis in original]

Third Edn. Crosby Lockwood & Son, London.

Clement Stretton’s quote, albeit about signals, is as apposite today as it was in 1893. Concerns by staff may not receive attention until it too late. But at Croydon, drivers did not ‘constantly complain’; they did not complain at all.

Following the accident RAIB conducted an attitude survey of drivers:

“227 Of the 59 [of 143] drivers responding to the RAIB’s driver questionnaire, 21 reported that they had missed their initial braking point approaching the south curve at Sandilands. Nine responses indicated that drivers had used the hazard brake to comply with the … 12 mph … speed restriction around the curve and other drivers reported the need for heavy braking. None of these incidents had been reported to line controllers.

228 Responses … indicate that the absence of reporting was a consequence of drivers believing that this would result in unnecessary action (eg excessive monitoring) and/or disciplinary action being taken against them …. Among drivers responding to the questionnaire, 29 out of 59 respondents (49%) felt that self-reporting a driving mistake or irregularity would have this consequence.

229 Had more drivers felt they were able to self-report irregularities, such as missing braking points and then using the hazard brake or heavy full service braking, it is possible that TOL might have identified the need to investigate the reasons why these events were occurring on the approach to Sandilands south curve and then taken any necessary action, such as briefing all drivers or requesting improvements to the infrastructure.”

So how could drivers report their concerns without fear of retribution?

FirstGroup (the parent company of TOL) had in fact a telephone confidential hot line (RAIB report paragraph 225, not reproduced here). The RAIB infers that no driver contacted it. If so, there are plausible reasons: it might not be perceived as sufficiently independent, and perhaps difficult to use in confidence (as the hot line seems also to be a non-confidential facility).

I think that CIRAS’s modus operandi is an optimum scheme where not only is confidentiality assured, but CIRAS’s independent expert team reviews both the report and the organisation’ response, taken (in some cases following robust debate), to closure.

The Report does not make any recommendations regarding CIRAS. It does tackle the first priority:

“12 [re-ordered]

[TOL] should undertake a review … covering the way that it learns from operational experience. The areas the review should address are:

i. fostering the creation of a ‘just culture’ in which staff are more likely to report incidents and safety-related concerns; …”

This recommendation is intended to encourage an organisational culture in which tram drivers feel able and willing to report safety incidents, and in which TOL takes suitable actions in response to information from both staff and the public. ...” [Emphasis in original paragraph]

CIRAS exists because a ‘just culture’ is a vital aspiration but can ‘never’ be wholly relied upon. CIRAS exists essentially for two purposes. First, to allow reporters with concerns to raise issues that have not, in their view, received attention in their companies (about 75% of CIRAS reports), echoing the Stretton quote. Secondly, to encourage reporting by staff who may feel inhibited to talk to their employers, for whatever reasons. What matters is that, as this post suggests, reporting to CIRAS may prevent bad events, and conversely that non-reporting may lead to managers living in a fools’ paradise. A further benefit of CIRAS reporting is that it obliges companies to reflect on the concerns that have been brought to their attention.

It can only be speculation what might have been different if just one TOL driver had made a report to CIRAS. With all the variables involved, perhaps nothing. But it is the generality that matters. CIRAS is a ‘long stop’ that plays a major part in improving communications and feedback in the transport industries. It is valued by member companies. Managers may reasonably believe that all is well. A CIRAS report may promote a more realistic perspective.

All transport companies should join CIRAS. Indeed, it is an exemplar of what should be adopted in other industries where staff are reticent to raise concerns perhaps through fears of retribution. For in many organisations ‘whistle blowing’ is the only route. Organisations like CIRAS offer an alternative, less divisive, independent service.

The RAIB Report focussed on the breakdown of communications between drivers and their supervisors at an operational level. But the deficiencies on the Croydon route were also a consequence of long standing fallible decisions, notably the apparent non-involvement the drivers in risk assessments. TOL’s response to a ‘fatigue’ concern mentioned above was to emphasise trade union involvement. Why were drivers not involved in the assessments?

I would personally welcome more CIRAS reports on topics that go to the root of transport safety management, in this case participation in risk assessments. For my conclusion is that the drivers knew far more about the hazards on the line than their managers.